Loss Of Control InflightAn Approach to Enhance Safety

Loss Of Control Inflight

TOP 3 HIGH-RISK OCCURRENCE CATEGORIES(TOT7)

R/W SAFETY RELATED

CONTROLLED FLIGHT INTO TERRAIN

LOSS OF CONTROL IN-FLIGHT

Loss Of Control Inflight

0% 10% 20% 30% 40% 50% 60% 70%

CFIT

LOCI

Rwy Safety Related

2%

3%

62%

13%

60%

6%

Fatalities Accidents

Observations from 2013 ICAO Safety Report 2014

Loss Of Control Inflight

0% 10% 20% 30% 40% 50% 60%

CFIT

LOCI

Rwy Safety Related

2%

2%

54%

5%

31%

0%

Fatalities Accidents

Observations from 2014 ICAO Safety Report 2015

Loss Of Control Inflight

LOCI9%

Others

Accidents %

LOCI

OTHERS

2010-2014 Fatal Accidents, IATA Reports

Loss Of Control Inflight

LOCI49%OTHERS

Fatality %

LOCI

OTHERS

2010-2014 Fatal Accidents, IATA Reports

Loss Of Control Inflight

LOCI49%

OTHERS

Fatality %

LOCI

LOCI9%

Others

Accidents %

LOCI

OTHERS

Loss Of Control Inflight

104

118

99

90

98

0

20

40

60

80

100

120

140

2010 2011 2012 2013 2014

Accidents

ICAO Safety Report 2015

Loss Of Control InflightLOC-I Threats:

Weather

ATC

CREW

Aircraft

Loss Of Control Inflight

Loss Of Control Inflight

Loss Of Control Inflight

Loss Of Control InflightCREW

Knowledge: Aircraft Limitations, Weather and its Avoidance

Proficiency: State of the Art Simulators Nowadays can Simulate every manoeuver required such as Stall Recovery, High Pitch Angles, Steep Bank Angles, Wind Shear, Collision Avoidance.

Situational Awareness: Crew should always be ahead of the Aircraft, and never be Complacent resulting from High Degree of Automation.

Loss Of Control Inflight

Loss Of Control Inflight

Thank You

Developing and Implementing

Regional LOC-I Safety Enhancements

George Rhodes

Assistant Director Infrastructure

IATA MENA

Fatal Accidents by Categories

18

Accident Frequency and Survivability

19

Loss of Control Inflight Accidents

2010 - 2014

There were a total of 415 commercial accidents

during this period:

38 of these accidents were LOC-I

37 were fatal accidents

Resulted in 1,242 out of 2,541 fatalities

20

LOC-I Accidents by Region

21

26% 13% 18% 8% 18% 5% 11% 0%0

2

4

6

8

10

12

AFI

ASP

AC

CIS

EUR

LATA

M

MEN

A

NA

M

NA

SIA

LOC

-I A

ccid

en

ts

LOC-I Accidents: Region of Operators10

5

7

3

7

2

4

Source: IATA GADM

LOC-I Fatal Accidents by Region

22

10

5

7

2

7

2

4

00

2

4

6

8

10

12

AFI

ASP

AC

CIS

EUR

LATA

M

MEN

A

NA

M

NA

SIA

LOC

-I A

ccid

en

ts

LOC-I Fatal Accidents: Region of Operators

Source: IATA GADM

Contributing

Factors

Latent Conditions (deficiencies in...) Errors (related to…)

Flight Operations 24% Manual Handling / Flight Controls 29%

Safety Management 24%

SOP Adherence / SOP Cross-verification

26%

Flight Ops: Training Systems 18% Intentional 16%

Regulatory Oversight 18% Unintentional 11%

Flight Ops: SOPs & Checking 13% Callouts 8%

Environmental Threats Undesired Aircraft States

Meteorology 37% Vertical / Lateral / Speed Deviation 21%

Icing Conditions 13%

Operation Outside Aircraft Limitations

16%

Poor visibility / IMC 13% Unnecessary Weather Penetration 16%

Thunderstorms 13% Unstable Approach 11%

Lack of Visual Reference 11% Abrupt Aircraft Control 5%

Airline Threats Countermeasures

Aircraft Malfunction 37% Overall Crew Performance 32%

Contained Engine Failure/Powerplant Malfunction

24%

Contingency Management 16%

Operational Pressure 8% Captain should show leadership 11%

Fire / Smoke (Cockpit/Cabin/Cargo) 5% Leadership 11%

Monitor / Cross-check 11%

23

24

Contributing

Factors –

Latent

Conditions

25

Contributing

Factors –

Undesired

Aircraft State

26

LOC-I Accidents in

MENA

Percentage

of

Commercial

Accidents

Versus

Total

Accidents -

MENA

27

LOC-I

Accidents

in MENA

per Year

28

Contributing Factors in LOC-I: MENA Region

29

Meteorology and Aircraft Malfunction were cited as contributing factors

30

5 W’s of RASG-MIDWhat is RASG-MID?

Regional Aviation Safety Group for the MID region

When & Where was it established? ICAO Council approval on 25 May 2010 to establish RASGs

RASG-MID kick off on 18 – 19 September 2011 in Cairo, Egypt

Why was is established? Develop an integrated data driven strategy, and implement a

work program that supports a regional performance framework

for the management of safety on the basis of the GASP

Who can participate? Members: Contracting states (ICAO MID region)

Observers: Non contracting states & Organizations

31

RASG-MID Contracting States…

MID Region

15 States…

Libya, Egypt, Sudan, Jordan, Syria, Lebanon,

Iraq, Kuwait, Qatar, Bahrain, UAE, Oman,

Saudi Arabia, Yemen, Iran

32

RASG-MID Permanent Observers

33

ICAO Council

Air Navigation Commission

RASG MID

RASG MID Steering

Committee

Annual Safety

Report Team

Regional

Aviation Safety

Team

Safety Support

Team

Runway &

Ground Safety

Working Group

RASG-MID

Structure

34

What we do Collect safety information from different

stakeholders Identify & address aviation safety risks in

the MID region Produce the annual safety report

1st Edition, Nov 2012 2nd Edition, Jan 2014 3rd Edition, March 2015 4th Edition, In progress

Data sources: States & Organizations

Annual Safety Report Team (ASRT)

35

What we do

Develop & implement SEIs and DIPs related to focus areas identified by the ASRT

SEIs & DIPs include: Development of training &

guidance material Holding regional workshops &

seminars Go teams

Regional Aviation Safety Team (RAST)

36

What we do

Support the RASG-MID steering committee with safety initiatives not directly related to key focus areas such as:State safety program (SSP)/Safety Management

Systems (SMS) implementationEstablishment of Regional safety oversight

organizations (RSOO)English language proficiency (ELP)…etc

Safety Support Team (SST)

37

Workflow for the three teams…

38

RASG-MID uses different types of

safety information

REACTIVE: safety analysis based on accidents and serious incidents in MID region

PROACTIVE: includes analysis of existing State conditions (ICAO SARPs implementation, traffic variations), IOSA, ISAGO audit results, and STEADES data

PREDICTIVE: based on analysis of Flight Operations Quality Assurance (FOQA) de-identified data, oriented towards identifying potential future hazards for initiating corresponding mitigation actions –an area for improvement!

39

Safety Data Analysis

Risk assessment based on:

FrequencySeverity (fatality)

Accident Category Frequency Severity Frequency*Severity

Runway/ Taxiway Excursion 1* 2 2

Ground Safety 1* 3 3

Gear up Landing / Gear Collapse 3 3 9

Hard Landing 4 3 12

Loss of Control In Flight 5 1 5

Controlled Flight Into Terrain 6 1 6

Top Risk Areas in the MID Region

Runway Safety

Loss of Control In-flight (LOC-I)

System Component Failure – NEW!

40

Loss of Control – Inflight (LOC-I)

MID- Regional Aviation Safety Team (RAST)

MID-RAST Process 1. Develop short and medium term regional safety priorities

based on identified Focus Areas (FAs)

2. Develop SEIs for the identified FAs;

3. Provide recommended actions through the development

of Detailed Implementation Plans (DIPs)

4. Monitor the implementation of DIPs and provide feedback

to the RSC; and

5. Review DIPs with MID-RSC & RASG-MID

6. Approval of DIPs by RASG-MID

7. Implementation & Monitor progress (IATA MENA + stake

holders

42

Loss of Control In-Flight (LOC-I)

LOC-I/1: Airplane State awareness (ASA) -Low

airspeed alerting

LOC-I/2: Standard Operating Procedures

effectiveness and adherence ;and

LOC-I/3: ASA-Training-Flight Crew Training

Verification and Validation

43

LOC-I/1 :Airplane State awareness (ASA)-

Low airspeed alerting

Compiled statistical data to identify the number

of operators and their fleet in MID region.

1481 aircraft registered in the MID Region.

Consulted with manufacturers of aircraft to

determine the status of their fleet.

44

ASA MID fleet Status (1)

949 New Generation aircraft with glass cockpit having

the provision of low speed alert. Represents 64%

compliance rate

217 Classic western built aircraft representing 15 % of

the total fleet in Mid Region

123 Regional Jets representing 8%

124 Eastern built aircraft representing 8%, mainly in Iran,

Libya and Sudan

68 Turbo Prop aircraft representing 5 %

45

ASA fleet Status (2) Basic on Boeing 787, 777, 747-8, 767-400 {with the

Large Format Display Systems (LFDS)} and 747-400.

Optional on Boeing 737-600/700/800/900 (service

bulletin available (SB 737-34A2292).

No Option on Boeing 757, 727, MD-90, MD-80, 737-

100/200/300/400/500 or the 767.

Basic on Airbus A320 family, A330, A340, A350 and

A380

Not basic on A300 & A310.

46

LOC-I/1 :Airplane State awareness

(ASA)-Low airspeed alerting

The ICAO ANC highlighted that the work on Low Airspeed

Alerting provisions was excellent material and the ANC

should consider referring this work to the AIRP for further

review.

47

LOC-I/2 :SOPs effectiveness and adherence

Many aviation safety organizations recently reaffirmed the

importance of SOPs.

identified deficiencies in SOPs as contributing causal factors in

aviation accidents.

commonly cited deficiencies involving flight crews non-compliance

with established procedures; or the non-existence of established

procedures in some manuals.

Airlines should consult with manufacturers to check that

SOPs are consistent with current manufacturer

recommendations with regards to LOC-I and CIFT.

48

LOC-I/3 :Flight Crew Training (1)

Upset prevention and recovery training, including

the following:

1. Qualification of flight simulators to satisfactorily

represent aircraft characteristics for proposed scenarios

Coordinate with airplane and simulator manufacturers

to ensure that simulators satisfactorily represent

aircraft characteristics for proposed scenarios

2. Approach-to-stall training in realistic scenarios

3. Upset prevention and recovery training (UPRT) realistic

scenarios

49

LOC-I/3 :Flight Crew Training (2)

Approach-to-stall training in realistic scenarios.

(i.e., up to the stall warning activation):

approach-to-stall with the autopilot engaged (including

auto-throttles disengaged, inoperative or not installed

a demonstration of recognition and recovery from initial

improper response to approach-to-stall.

high-altitude approach-to-stall (service ceiling for the

weight)

low-altitude approach-to-stall (terrain critical) and recovery

with ground proximity warning system (GWPS) alerts

air data system failures that can lead to stall

50

LOC-I/3 :Flight Crew Training (3)

Upset prevention and recovery training (UPRT)

realistic scenarios including but not limited to:

Upsets encountered with and without auto-flight

engaged.

Upsets occurring in instrument meteorological

conditions (IMC)

Sub-threshold roll (imperceptible roll rate) in IMC

Pilot-induced upsets

Air data system failures (e.g., unreliable airspeed)

51

Ref. Documentations

IATA Guidance Material and Best Practices for the

Implementation of Upset Prevention and Recovery

Training (First edition effective June 2015)

ICAO Doc.10011 Manual on Aeroplane Upset Prevention

and Recovery Training

Annex 6 ;ICAO AMENDMENT 38 on UPRT

52

Q&ATHANK YOU